Provider Demographics
NPI:1386687200
Name:MOHR, DAVID JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JEFFREY
Last Name:MOHR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3600
Mailing Address - Country:US
Mailing Address - Phone:985-732-0058
Mailing Address - Fax:985-732-0019
Practice Address - Street 1:420 AVENUE F
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3600
Practice Address - Country:US
Practice Address - Phone:985-732-0058
Practice Address - Fax:985-732-0019
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080D17690OtherBLUE SHIELD
MI3118953Medicaid
MI4098967OtherAETNA
MI080D17690OtherBLUE SHIELD
MI3118953Medicaid
MI0D1769007Medicare ID - Type Unspecified